Mboane and Bhatta Reproductive Health (2015) 12:36 DOI 10.1186/s12978-015-0010-2
RESEARCH
Open Access
Influence of a husband’s healthcare decision making role on a woman’s intention to use contraceptives among Mozambican women Ramos Mboane and Madhav P Bhatta*
Abstract Background: Previous studies in developing countries suggest that a husband plays an influential role in a woman’s contraceptive use. The influence of a husband/partner’s healthcare decision making power on a woman’s intention to use contraceptives in Mozambique has not been studied. The present study examined this relationship using data from the 2011 Mozambique Demographic and Health Survey (DHS), which included a nationally representative sample of 7,022 women aged 15-49 years. Methods: The primary outcome of interest in the study was a woman’s intention to use contraceptives. The primary exposure of interest was the person making decisions about a woman’s healthcare, dichotomized as the husband/partner alone vs. the woman herself or jointly with her husband/partner. Several potential socio-demographic confounders were adjusted for in overall and stratified multivariable logistic regression models. Adjusted odds ratio (AOR) and the associated 95% confidence interval (CI) are reported. Results: The mean age of the sample was 30.4 (95% CI: 30.1 - 30.7) years. Overall, a woman who reported her husband/ partner usually made the decision about her healthcare was 19% less likely to report an intention to use contraceptives than a woman who reported that she herself or jointly with her husband/partner made the decision (AOR = 0.81, 95% CI 0.71- 0.92). In stratified analyses, the association remained statistically significant among rural women (AOR = 0.75, 95% CI: 0.65 - 0.87); among women with knowledge of modern contraceptive methods (AOR = 0.83, 95% CI: 0.73 - 0.95); and among women with three or more (AOR = 0.81, 95% CI: 0.68 - 0.97) and two or fewer (AOR = 0.79, 95% CI: 0.65 - 0.96) living children. Conclusions: A husband/partner’s healthcare decision making power in the relationship had a significant negative effect on a Mozambican woman’s intention to use contraceptives. These findings have implications for addressing the role of men in the design and implementation of successful family planning programs to improve the contraceptive uptake rate among women in Mozambique. Keywords: Contraceptive use, Husband or partner’s influence, Healthcare decision making power, Intention to use, Mozambique
Background Family planning is regarded as one of the ten greatest public health achievements of the 20th century [1]. Despite the far reaching impact of family planning on the health and well-being of children, women, and families [2-5], modern contraceptive use in the developing world, * Correspondence:
[email protected] Department of Biostatistics, Environmental Health Sciences, and Epidemiology, College of Public Health, Kent State University, 750 Hilltop Drive, 319 Lowry Hall, P. O. Box 5190, Kent, OH 44242, USA
especially in Africa, remains low [6]. In Mozambique in 2003, the prevalence of any method of modern contraceptive use among women of reproductive age who were married or were in union was 11.8% [6]. Almost a decade later, the 2011 contraceptive use rate in this group of women remained virtually unchanged at 11.5% [7]. Understanding the barriers to modern contraceptive use in Mozambique would assist policy makers and planners in developing targeted family planning programs for increasing the contraceptive use rate.
© 2015 Mboane and Bhatta; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Mboane and Bhatta Reproductive Health (2015) 12:36
Women in developing countries face multifaceted and challenging barriers to modern contraceptive use. A complex interplay of demographic, social, cultural, and economic factors contribute to a woman’s failure to use modern contraception. The influence of the male partner on a woman’s reproductive health decisions is an important area of reproductive health research that has garnered greater attention in the last decade [8]. Several previous studies in developing countries suggest that the husband exerts a significant influence on a woman’s decision to use contraceptives [8-10]. Even well-educated women who desire to use contraceptives fail to do so because of their husband’s objection to family planning. For example, in a study from Ghana a husband’s attitude toward family planning was found to strongly influence the wife’s attitude toward contraception [9]. Similar findings were reported in Pakistan, where women faced with making a decision about family planning tend to base their decision on their husband’s fertility preferences and attitudes toward family planning [10]. To the best of our knowledge, there are currently no studies that have examined the role of a husband/partner on a woman’s current contraceptive use or her future intentions of contraceptive uptake in Mozambique. This study aims to understand the influence of a husband/ partner’s healthcare decision making power on a woman’s intention to use contraceptives among a nationally representative sample of reproductive aged (15-49 years) women in Mozambique. Quantifying this relationship would provide additional useful data for reproductive health program planning in Mozambique.
Methods Study setting
Mozambique, located in south-eastern Africa, is administratively divided into 11 provinces and 128 districts. The 11 provinces are divided into three geographical regions: the North, the Central, and the South. The population of Mozambique in 2013 was approximately 24 million and women of reproductive age comprised about 24% of the total population. In 2010, the total fertility rate was 5.1 children per woman. The majority of the population in Mozambique is rural (69%) and subsistence agriculture is the main economic activity [11,12]. The healthcare system in Mozambique is predominantly supported by the public sector and consists of the primary (652 health posts and 435 health centers), secondary (27 rural and 8 district hospitals), tertiary (5 general and 7 provincial hospitals), and quaternary (3 central hospitals) levels [13]. While all levels of the public healthcare system provide reproductive health services, mostly free of charge, the primary level plays the most significant role in the promotion and delivery of family planning services.
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Study design and sampling
This cross-sectional study utilized the data from the 2011 Mozambique Demographic and Health Survey (2011 MDHS). The data for the study was down loaded, with permission from the Demographic and Health Survey website at: www.dhsprogram.com/data/availabledatasets.cfm. The sampling procedures and survey instrument design have been published in detail previously [7]. Briefly, the 2011 MDHS was a stratified twostage cluster sampling designed to collect nationally and regionally representative data on population and health indicators. In the first stage, 611 primary sampling units (256 in urban and 355 in rural areas) were identified using a Differential Global Positioning System (DGPS). In the second stage, a representative sample of 13,964 households was randomly selected. Homeless people, and households and individuals living in collective shelters such as hotels, hospitals, military units, and student housing were excluded from this sampling process (this represented an exclusion of 3.3% of the total population). In all 13,871 women of reproductive age (ages 15 – 49 years) eligible for an individual interview were identified from the households selected in the sample and 13,718 of them were interviewed (99% response rate). A total of 7,022 women who were in a union (had a husband or a partner) and had complete information on the primary exposure and main outcome of interest were included in the present analysis. Survey instrument and data extraction
The DHS data were collected during face-to-face interviews using tablet computers equipped with a CAPI System (Computer-Assisted Personal Interview) using three questionnaires: the Household, the Women’s, and the Men’s Questionnaire. For the purpose of this study, the Individual Recode Women Dataset derived from the Women’s Questionnaire was used. The Women’s Questionnaire collected data on age, education, religion, reproductive history, knowledge and use of contraceptive methods, antenatal care, marriage and recent sexual activity, fertility preferences, husband’s background, woman’s status, and domestic violence. Portuguese was the language used in the questionnaires, and all the survey instruments were pre-tested in urban and rural areas in the Bilene Macia District of Gaza Province in February 2011. Manual and automatic procedures such as verification of questionnaires, revision and codification, and editing and analysis of inconsistencies were used for data quality assurance and control. Data entry was conducted using microcomputers equipped with Census and Survey Processing System (CSPro) software. Primary outcome of interest
The primary outcome of interest in this study was a woman’s future intention to use modern contraceptives
Mboane and Bhatta Reproductive Health (2015) 12:36
measured using the question: are you thinking about using any contraceptive method to delay or avoid getting pregnant in the future? The possible responses to the question included: plan to use the methods within the next 12 months; plan to use the methods in the future with no time specified; unsure about use; and does not intend to use the methods. These responses were categorized as those who intended to use the methods in the future, those who did not intend to use the methods, and those who were unsure about use in the available MDHS 2011 dataset. Those in the unsure about use category were excluded from the present analysis. Thus, the outcome was dichotomized as: those who intended to use contraceptives in the future and those who did not intend to use. To avoid loss of statistical power, observations with missing information on covariates other than the primary exposure and the outcome were not excluded but were treated as missing data.
Primary exposure of interest
The primary exposure of interest in this study was the person who usually made the decision on the respondent’s healthcare. This was designed to capture the information on the individual in the family who had the decision making power in regards to the respondent’s healthcare needs and was measured with the question: who usually makes the decision about your healthcare? The possible responses included: respondent alone, husband/partner alone, respondent and husband/partner jointly, someone else, and other. The latter two groups were excluded in this analysis as they were not related to the research question of interest. The response levels for the primary exposure were dichotomized as: the respondent alone or jointly with husband/partner and the husband/partner alone. The rationale for combining respondent alone and joint decision making responses were two-fold: i) there were only a small proportion of the women reporting making the healthcare decision on their own, and ii) the question of interest was whether a husband as a sole healthcare decision maker had an influence on a woman’s contraceptive use intention compared to a decision making process in which a woman was involved.
Potential confounders
The following potential confounding variables were included in the study: respondent’s age, educational level, employment status, religious beliefs, knowledge about modern contraceptive methods, region of residence, type of place of residence (rural vs. urban); cohabitation status with the husband/partner; number of living children; and husband/partner’s education and desire for children.
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Data analysis
DHS surveys apply the household weights and the individual sampling weights to account for differences in the probability of selection and interview between observations in the study. The use of sampling weights in the analysis is appropriate when calculating representative levels of statistics such as proportions, means, and medians. However, to avoid overestimation of the measure, use of samplings weights is not recommended for estimating relationships such as regression and correlation coefficients [14]. Therefore, the sampling weights [7] were applied to the calculations of proportions and means in the study but not to the logistic regression models. Overall and stratified univariable and multivariable logistic models examined the association between the primary exposure and outcome and the associated odds ratio and 95% confidence intervals (OR; 95% CI) were computed. Data analysis was performed using SAS 9.3 (SAS Institute Inc, Cary, NC, USA) applying SAS Survey procedures (PROC SURVEYFREQ, PROC SURVEYLOGISTIC) to obtain correct estimates and to account for the complex sampling design, when appropriate. Ethics statement
This study was conducted using secondary data analysis from the 2011 MDHS dataset. The data collection methods for the 2011 MDHS, including the consent process, have been previously described [7]. Written informed consent for the present analysis was not necessary because secondary data analysis did not involve interaction with the participants. This study was approved by the Kent State University Institutional Review Board as a Level I Exemption Category 4 (Existing Data, Documents, and Specimens) research protocol (#13-578).
Results Sample characteristics
The mean and median ages of the study sample were 30.4 (95% CI: 30.1 – 30.7) and 29.0 (95% CI: 28.6 – 29.5) years. The mean and median number of living children a woman had were 3.0 (95% CI: 2.9 - 3.0) and 2.2 (95% CI: 2.1 - 2.24; range: 0 – 12). Table 1 presents the prevalence of various socio-demographic characteristics and contraceptive use in the study sample. Overall, 38.5% (95% CI: 37.2 – 39.9) of the women reported having no formal education and 41.5% (95% CI: 40.2 – 42.8) reported currently working. Seventy-four (95% CI: 73.4 – 74.3) percent of the women lived in rural areas. Eighty-six percent (95% CI: 84.7 – 86.5) of the women reported that their husband/partner was living with them. Overall, 39.3% (95%: 37.7 – 40.0) of the women reported both she and her husband wanted the same number of children, while 55.2% (95% CI: 53.6 – 56.7) reported that their husband wanted more children than they did. Ninety-six percent (95% CI:
Mboane and Bhatta Reproductive Health (2015) 12:36
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Table 1 Sample characteristics of reproductive aged women (15 - 49 years) in the 2011 DHS§-Mozambique Characteristic
Frequency
Weighted proportion estimate (95% Confidence Interval) Overall (N = 7,022)
Person making decisions about the respondent’s health Respondent alone or jointly§§
Husband/ partner alone
(n = 5,028)
(n = 1,994) 0.098
Age, years 15 – 24 25 – 34 35 – 44 45 – 49
2,182
2,515
1,704
621
31.29
30.12
33.68
(29.99 - 32.59)
(28.58 - 31.66)
(31.26 - 36.09)
35.19
35.85
33.83
(33.85 - 36.53)
(34.25 - 37.44)
(31.3 - 36.30)
24.51
24.69
24.13
(23.29 - 25.72)
(23.25 - 26.12)
(21.87 - 26.40)
9.02
9.34
8.36
(8.20 - 9.84)
(8.36 - 10.33)
(6.88 - 9.83)
38.54
36.27
43.18
(37.19 - 39.89)
(34.69 - 37.85)
(40.64 - 45.72)
52.23
52.99
50.65
50.83 - 53.62)
(51.35 - 54.65)
(48.06 - 53.23)
9.23
10.73
6.17
(8.54 - 9.93)
(9.87 - 11.59)
(5.01 - 7.34)
